A simulation study analyzing the harms, advantages, and costs associated with different guideline recommendations for initial evaluation of hematuria found that no approach diagnoses every cancer and suggest that the incremental costs and radiation-associated harms occurring with the most intensive recommendation, which advocates a one-size-fits-all approach with computed tomography scanning, may outweigh marginal benefits in terms of diagnostic yield, said Matthew E. Nielsen, MD, MS.
“The rationale for aggressively testing a larger fraction of the population that presents with hematuria is to minimize the risk of missing any cancer, and that is a reasonable and well-intentioned rationale. However, the fact that current guidelines for hematuria evaluation provide differing recommendations reflects that there is some uncertainty about the best strategy in this space,” said Dr. Nielsen, of the University of North Carolina School of Medicine, Chapel Hill.
He continued, “The variability in recommendations and our study’s findings highlight implicit value judgments and a potentially high burden of harms not historically considered in many guidelines’ development process. Urologists may want to consider discussing with patients the relative benefits and harms associated with different approaches and potentially consider applying risk-stratified approaches that focus the most intensive testing on the highest risk patients as a way to improve the value of care for this patient population.”
For the analysis, which was published online ahead of print in JAMA Internal Medicine (July 29, 2019), a microsimulation model was developed to assess urinary tract cancer detection rates, radiation-induced secondary cancers from CT radiation exposure, procedural complications, false-positive rates per 100,000 patients, and incremental cost per additional urinary tract cancer detected for a hypothetical 100,000-patient cohort evaluated according to the recommendations from five different guidelines.
The guidelines evaluated were (listed in order of increasing intensity) the Dutch, Canadian Urological Association, Kaiser Permanente, Hematuria Risk Index, and the AUA. The characteristics of the patient cohort were derived using data from the two largest published series of patients undergoing evaluation for hematuria and included subsets with gross hematuria as well as microscopic hematuria. All patients were assumed to be 35 years of age and older.
Diagnostic yields for bladder cancer, renal cell carcinoma (RCC), and upper-tract urothelial cancer (UTUC) were considered separately and as a function of which patients would undergo cystoscopy and imaging and with which modality. Real-world data on CT radiation doses were used to account for variations that exist in clinical practice.